Understanding and Documenting Opioid and Other Substance Use Disorders for SSI/SSDI Claims

Co-Occurring Disorders

According to SAMHSA’s National Survey on Drug Use and Health in the United States, an estimated 52.9 million (21%) adults aged 18 and older experienced mental illness in 2020. In that same year, 5.7 million adults (2.2%) had both a mental disorder and substance use disorder, also known as a co-occurring disorder.¹

SSA’s policy on substance use disorders

The Social Security Administration (SSA) has very specific guidelines regarding substance use. Sections 223(d)(2)(C) and 1614(a)(3)(J) of the Social Security Act state that an applicant shall not be considered to be disabled if alcoholism or drug addiction would be a contributing factor material to the Commissioner's determination that the individual is disabled.² In other words, would the applicant still experience disabling symptoms if he or she was clean and sober? If yes, then substance use is not material to his or her disability.

What does this mean for a SOAR-assisted SSI/SSDI claim?

Given the high prevalence of co-occurring disorders, it is critical to understand the implications for SOAR-assisted applications. This is particularly important when it comes to writing the Medical Summary Report (MSR). Disability Determination Services (DDS) can deny an application if they determine that substance use is material to the applicant’s disability.

How do we effectively document substance use in the MSR?

A detailed substance use section in your MSR will provide invaluable information to help the Disability Examiner determine the “materiality” of an applicant’s substance use disorder.

Critical sources of information

• Inpatient, outpatient, jail, and hospital records
• Neuropsychological evaluations
  • Can provide important information about any permanent impact on the applicant’s brain functioning due to substance use
• Family, close friends, shelter staff, and case managers
• Direct observations by the SOAR case manager

Organizing the Substance Use Section

• Start by discussing initial use
  • What was going on in the applicant’s life?
  • How did using substances affect the applicant at that time?
• Discuss treatment in chronological context
  • When did the applicant first receive treatment?
• Initial treatment may be instigated by family or law enforcement
  • How did they respond to treatment?
  • What happened in between treatment episodes that led to relapse?
• Provide information about the applicant’s current use of alcohol or other drugs
  • When was the last time the applicant used substances?
  • What symptoms does the applicant experience when not using substances?
  • What impact does the applicant think substance use has had on his or her life?

Paint the picture!

• Use a variety of information sources to clearly illustrate the applicant’s relationship with substances.
• Always provide the context of substance use, so DDS can understand how mental illness may play a role.
• Use quotes from the applicant to help accurately describe his or her substance use or cooccurring disorder.
• Have a colleague review the redacted report! Does your colleague understand the full picture of the applicant’s relationship with substances and co-occurring disorder, based on the details provided?

Resources

SAMHSA

• Opioid Treatment Directory
• SAMHSA’s National Helpline: 1-800-662-HELP (4357) TTY: 1-800-487-4889 or https://www.samhsa.gov/find-help/national-helpline

SAMHSA SOAR TA Center

• Medical Summary Report Interview Guide and Template
• Sample MSR with Substance Abuse

¹National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration (SAMHSA). 2020. Note: The 2020 survey marked the first year in which SUDs were assessed using the criteria defined in DSM-5 instead of DSM-IV.

²SSR 13-2p: Titles II and XVI: Evaluating Cases Involving Drug Addiction and Alcoholism (DAA). Social Security Administration. 2013.